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4 !RI0 CITY OF PRIOR LAKE Date Rec'd
H
, HEATING /AIR CONDITIONING /FIREPLACE PERMIT ` 0 ( 1 I
r ,� L1l
U hr
lMvssoo I. rink File / PERMIT NO. Gr City ! 3- ', j am"
3 .
I 3. Yellow Applicant / ///
(Please type or print and sign at bottom)
ADDRESS ZONING (office use)
■
` 130 1 6 4 a & e Pir jc / v
LEGAL DESCRIPTION (office use only)
LOT BLOCK / 1 ADDITION 0 /2i4(NG �1 /4,64f ' 3 y -
(N �/I a/4 K' &// t / z t el (Phone) C.5) , 3Y3 .9 385
(Address) 9 30/ C`'22.(/yjec3O j (4)) P
(Name) tO t L, r (Phone) YJ . ZS' �
(Address) liOW Ol n ,0J a a l)t 7 ir, i' 1 .5s(4)7
. (• dress) (City) (Zip Code)
l I
(Contact Person) 1 ,f1t /. 4 , /L (Phone) 7E0383 IS ) O
APPLICANT SIGNATU • : 4_,,/„A DATE '
A ' LICANT PLEASE COMPLETE BELOW •
DNEW CONSTRUCTION cEPLACEMENT 0 ALTERATIONS
FURNACE MAKE AND MODELTDIg ftL___ (_1 d C' )DO l FUEL Nal (
FLUE SIZE RETURN OPENINGS INPUT /0Q 000 OUTPUT
TYPE OF SYSTEM HEATING OR POWER PLANT
❑Warm Air Plants PLEASE NOTE: Air Conditioner
❑ Steam Units and Fireplaces Cannot Encroach
❑Gravity 0 Hot Water into Required Side Yard Setbacks.
,.4 i echanical ❑ Radiation
it Conditioning ❑Special Devices Fireplaces with Box Additions or
❑ ent. System 0 Other Devices Cantilevers to the Outside of Buildings
Require a Building Permit.
FIREPLACE MAKE AND MODEL
FEE SCHEDULE
Industrial, Commercial & Multi- Family I% of job cost Residential, Gas Fireplace $49.50
$49.50 minimum -;
Residential, Heating & A/C (New Construction) $149.50 Residential, Additions & Alterations $49.50
Residential, Heating Only (New Construction) $64.50 Residential, AC Ohly $49.50
Estimated Cost $ J $6. QQ_ 0 Building Permit #
��"TT��""" ,'1 The lvtinncsota Statutes § 32613.148
HEATING PERMIT FEE $ I C I ,5 0 "S( RC:11AR has been changed for one
year
.C— Year effective
STATE SURCHARGE $_ x.11 - s/Q July 1, 201(1, until .Lune 30, 2011.
TOTAL PERMIT FEE $ - (.. ac. • minimum surcharge for a "fixed fee" permit
(Office Use Only) eginniug duly 1.2010
This Application Becomes Your Building By Permit When Approved ild Receipt No.
Al
& �. c �
Bui l* a 0 Date / cial Date ( / //3 /q
24 hour notice for all inspections (952) 447 -9850, fax (952) 447 -4245
4646 Dakota Street S.E., Prior Lake, Minnesota 55372